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#Grand Rounds

Which Factors Increase Risk for High-Grade CIN 2/3 Recurrence Following Treatment?

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BACKGROUND AND PURPOSE:

  • Alder et al. (AJOG, 2020) examined
    • Long-term risk of residual/recurrent high-grade CIN among women previously treated for CIN 2/3 and association with margin status, posttreatment presence of high-risk HPV and other comorbidities

METHODS:

  • Prospective cohort study
  • Participants
    • Confirmed CIN 2/3
    • Underwent conization (2000 to 2007)
  • Study design and data analysis
    • Data from the Swedish National Cervical Screening Registry included
      • Primary histopathologic finding | Treatment modality | Comorbidity | Age | High-risk HPV status
    • Kaplan–Meier curves were used to plot cumulative incidence of residual/recurrent high-grade CIN
    • Management was standardized and based on margin status
    • Treatment modalities for CIN2/3: Electrosurgery with contoured-loop excision of the transformation zone (C-LETZ) most commonly used |  Electrosurgery with a diathermy needle | Laser (CO2) conization | Knife excision (rarely used)

RESULTS:

  • 991 women included
    • Residual/recurrent high-grade CIN or worse: 111 patients
    • Median follow-up: 10 years (maximum 16 years)
  • Positive/uncertain margins had a higher risk of residual/recurrent high-grade CIN or worse vs negative margins
    • Adjusted Hazard ratio (HR) 2.67 (95% CI, 1.81 to 3.93)
  • Residual margin location: Risk of residual/recurrent dependent on anatomical localization
    • Endocervical
      • HR 2.72 (95% CI, 1.67 to 4.41)
    • Both endocervical and ectocervical
      • HR 4.98 (95% CI, 2.85 to 8.71)
    • Only ectocervical margins (positive or uncertain)
      • Risk did not increase significantly
  • Comorbidities independently associated with residual/recurrent high-grade CIN or worse
    • Autoimmune disease
    • Human immunodeficiency viral infection
    • Hepatitis B and/or C
    • Malignancy
    • Diabetes
    • Genetic disorder
    • Organ transplant
  • Significant increased risk noted with positive high-risk HPV vs positive high-risk human papilloma virus findings but negative margins

CONCLUSION:

  • Incompletely excised CIN 2/3 is associated with greater risk for residual or recurrent high-grade CIN, or worse
  • The authors suggest that

Subdivided margin status might be used together with hrHPV status, and consideration of comorbidities to identify women at highest risk who are in need of re-treatment

Learn More – Primary Sources:

Incomplete excision of cervical intraepithelial neoplasia as a predictor of the risk of recurrent disease—a 16-year follow-up study

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Related ObG Topics:

What Are the Risk Factors for Recurrence after Large Loop Excision for CIN 2/3?
HPV Genotyping and Cytology for hrHPV: What Screening Combination is Best for CIN Detection?
Treatment for Women with HIV and High-Grade Cervical Lesions: Cryotherapy or LEEP?

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